Excision of mandibular vascular malformations via a lateral corticotomy approach

Abstract

Statement of the Problem: Traditional methods of treating “high flow” vascular lesions have often involved aggressive, cosmetically deforming surgery. Following embolization, ligation of feeder vessels, and sclerosis, the majority of literature recommends en bloc resection of the mandible with adequate surgical margins. This has been followed by immediate or delayed bone grafting. In a retrospective review analysis, 4 patients with high flow mandibular vascular lesions were treated with a lateral corticotomy technique and curettage of the tumor was then performed without creating a continuity defect of the mandible. Materials and Methods: Due to the paucity of these types of lesions, specifically within the mandible, the study ranged from 1997 to 2004. The 5 patients ranged in age from 1 to 38. Patients were all diagnosed with “high flow” vascular lesions of the mandible, mostly arteriovenous malformations. At the time of surgery, each patient had prior embolization by interventional radiology. During the procedure, direct puncture embolization also took place in all patients. A window of lateral bone was removed in all patients and the lesions removed by curettage, along with resection of the involved nerves, arteries, and veins. The lingual cortex and inferior border were left intact. All surgical cavities were left to fill in on their own except for one where allogeneic bone graft putty was placed. One patient required a reconstruction plate that was later removed. Follow-up was carried out for each of the patients at regular intervals, and a Panorex film was taken at several points in time. A follow up angiogram, CT, or biopsy was obtained if recurrence was suspected. Follow up times ranged from 2 weeks to 3 years. Results: All five patients were compliant with follow up. Patients followed for longer than 6 months had adequate bone fill. In one case a recurrence was noted at 3 years after surgery. This required a second lateral corticotomy slightly more anterior to the first. The remaining patients have not showed recurrence to date. Conclusion: Our study shows 80 percent success after the first attempt of treatment. The literature supports 67–75 percent success. In our series we avoided creating a continuity defect of the mandible, which allowed avoidance of some of the morbidity associated with complete resection. Traditional complications associated with mandibular plates were not present, because they were not used in the majority of our patients. Similarly, bone grafts were not placed, and so morbidity from a second surgical site was avoided as well. References Kaban LB, Bleaser B, Perrott DH: Head and neck vascular anomalies. Select Readings Oral Maxillofac Surg 5, 1997 Kademani D, Costello BJ, Ditty D, et al: An alternative approach to maxillofacial arteriovenous malformations with transosseous direct puncture embolization. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 97, 2004 (submitted for publication) Kohout MP, Hansen M, Pribaz JJ, et al: Arteriovenous malformations of the head and neck: Natural history and management. Plast Reconstr Surg 102:643, 1998